Background / Diagnostic Review
Orthodontics as a Dental Specialty
For a variety of reasons, orthodontics developed as the first specialty practice area in dentistry, and one of the first in health care more generally. When the American Board of Orthodontics was established in 1929 to certify specialists in this field, only two medical areas had already established specialty boards.
Why did orthodontics develop as a specialty so early? Edward Angle (image 1), the primary force in the development of modern orthodontics, became frustrated with trying to teach this subject in the dental schools of 100 years ago. He started his own school of orthodontics, with admission limited to those with a dental degree, and maintained it in various locations until just prior to his death in 1930. In 1901, he also established the American Association of Orthodontists, with membership limited to those who had training beyond dental school. In part because of this early tradition of postdoctoral training, orthodontics to this day receives less emphasis in the dental curriculum than most other areas of current dental specialty practice.
What does that mean for the interaction of orthodontists with other dentists? Simply that a higher percentage of patients with orthodontic needs are likely to be treated in a specialty practice, than those with most other types of dental treatment needs. If you practice in another area of dentistry, you would expect to interact with orthodontic specialists on a regular basis—more if you do no orthodontics yourself, less if you do, but regularly in either case.
Let’s explore a familiar situation for all dentists (image 2): You have been asked to look at a child and offer an opinion as to whether orthodontics is needed. It happens all the time in family practice, of course, but you’ll get asked about a friend’s child or patient’s child even if you’re in some other type of specialty practice.
 Image 1, Edward Angle: Edward Angle at age 50, as the master of his own orthodontic school. |  Image 2, consultation: To refer or not to refer? |
Facial Examination: Symmetry
In dental education, one of the goals is to equip dentists to recognize problems in dental and skeletal development. Obviously, if you don’t notice a deviation from normal, you won’t be in a position to either treat it yourself or refer it appropriately. Let’s quickly review the diagnostic evaluation of children.
The first, and the key step, in evaluating a child’s potential need for orthodontics is to carefully examine facial proportions. What are you looking for? Two things: symmetry and proportion.
The best way to evaluate symmetry is to look carefully at the patient from the front, drop a line from the forehead through the middle of the face, and look at how the nose and jaws are aligned relative to it (image 1).
A child with an obvious asymmetry is a candidate for immediate referral. Note that this boy’s chin deviates to the left. This reflects a serious growth problem with the potential to become steadily worse if left untreated.
Facial Examination: Jaw Proportions
A good way to sharpen your eye in looking at a child’s vertical facial proportions is to apply the “rule of thirds.” In both the frontal (image 1) and profile (image 2) views, the face should have approximately equal thirds from the hairline to the bridge of the nose, from the bridge to the base of the nose, and from the base of the nose to the chin.
Do these have to be exactly the same? Of course not, but if one area is noticeably short or long, you are looking at a potentially serious growth problem that should be evaluated sooner rather than later.
Note that the girl in these images has equal vertical proportions, while the boy has a noticeably short face, especially the lower third. These skeletal proportions predispose him to a deep overbite.
To judge the relative prominence of the mandible to the maxilla, use the profile view (image 2), and drop a vertical line across the front of the face when the patient is in natural head position. Now you can see the the girl’s chin is behind that line, so she has moderate mandibular deficiency, while the boy’s chin is as prominent as his upper lip but his lower lip is behind the upper lip.
She has a skeletal Class II malocclusion, he has a skeletal deep bite. But if face height is short, the mandible rotates upward and forward, which makes his chin more prominent—so he also would be Class II if you rotated his mandible downward to give him normal face height. That rotation also would improve the balance between his lower lip and chin. He’s deficient vertically and anteroposteriorly.
 Image 1, frontal: Normal vertical proportions vs short lower face. |  Image 2, profile: Mandibular deficiency, apparent with normal vertical, concealed with short vertical proportions. |
Facial Examination: Lip Prominence
Finally, especially in children who don’t have a jaw discrepancy, look carefully at the lips, and note two things: the amount of lip separation at rest, and the prominence of the lips.
Note that the girl in image 1 has relatively prominent lips, but little or no lip separation, while the one in image 2 also has prominent lips, but lips that are separated at rest.
Why is this important? Because crowding of the anterior teeth and protrusion of the lips are aspects of the same thing. You can’t evaluate crowding without also evaluating protrusion. The guideline is that the teeth are too protrusive, holding the lips too far forward, if two criteria are met: prominence of the lips, and lips that are separated at rest and strained on closure.
 Prominent lips, not separated at rest: incisor protrusion acceptable. |  Prominent lips, separated at rest: incisor protrusion excessive. |
 Lip separation, not lip prominence, is the key to deciding whether the incisors are too protrusive. |
Evaluation of Occlusion and Alignment/Crowding
Only after looking carefully at the face are you ready to examine the occlusion and alignment of the teeth. Look first at the occlusion in three planes of space: transverse [posterior crossbite], a-p [overjet], and vertical [overbite, open bite].
This child (image 1) has problems in all three planes of space. Note the posterior crossbite, excessive overjet, and anterior open bite. You’d have to look at her face (image 2) to know how much of this is due to her jaw relationships and how much is due to displacement of the teeth relative to their own jaw. She has enough mandibular deficiency to be skeletal Class II, and the lower third of the face is long, so there is a skeletal component to the open bite as well. Her face isn’t narrow, so widening the maxillary dental arch should be possible, but you would need to look at dental casts to evaluate the width of the palate.
Then you can examine the alignment of the teeth and the amount of space within each dental arch. Space analysis is the best way to quantify how much is available for the permanent teeth, but you can see at a glance whether the amount of space is adequate, a bit short, or seriously short. Of course if the space looks adequate but the teeth are too protrusive, that has to be entered into consideration about the best plan for treatment.
It’s obvious that both the lower arches shown in image 3 are crowded despite the reasonably good alignment of the permanent incisors after primary canines were lost prematurely. It’s also obvious that there’s less space in image 2 than image 1. How big is the space discrepancy in each case? You need to do space analysis to verify that.
 Note posterior crossbite, open bite, incisor irregularity. |  Note the long lower face and deficient chin: so there is a skeletal contribution to the open bite and a skeletal Class II tendency. |
 Early loss of primary canines: enough space? Space analysis needed to determine the severity of the potential crowding. |
Referral: What Cases, When?
Referral of Children for Orthodontic Care
All right, you have looked at both the face and the teeth, and you note some developmental problems with either the face or the dentition. Now what?
There are two major considerations in the referral of children from family practice to an orthodontist: (1) What type of problem warrants referral? (2) When (at what age) should the child be referred? Let’s consider those one at the time.
Common sense says that the more severe problems should be referred to a specialist, and the less severe ones can be treated in family practice. How do you determine which are the more severe ones?
The term triage describes the sorting of patients by the severity of their problems (and chance of survival) in disaster situations. For orthodontic problems, a similar sorting process, based on problem severity, is needed. This relates closely to the usual diagnostic evaluation that we just reviewed.
What Problems Warrant Referral: Orthodontic Triage
The first step in orthodontic triage for children is to look at the child’s face from the front, and evaluate two thing. First: Is there something so unusual about the child’s facial proportions or general appearance that a craniofacial syndrome may be present?
This boy was seen because of concern about anterior crossbite of retained primary teeth and failure of permanent teeth to erupt. He has the classic facies of cleidocranial dysplasia (short face, maxillary deficiency). He also has the absence of clavicles that is characteristic of the syndrome, so that he can almost bring his shoulders together. Before you even look in his mouth you should expect to find the multiple supernumerary and unerupted teeth that also are characteristic of this syndrome.
Patients with severe problems of this type obviously should be referred. Complete evaluation by a craniofacial team is indicated, because a correct syndrome diagnosis is a key to the planning of future treatment that may involve multiple medical and dental specialties.
Orthodontic Triage, Step 1 (cont.)
Looking at the child’s face from the front, the second thing to evaluate is facial symmetry: Is a true facial asymmetry present (not just a deviation of the jaw from initial contact of the teeth to full occlusion)?
We have already noticed that this boy’s chin is off to the left. Mentally putting a vertical line down the middle of his face, or using a ruler to establish a line, makes it easier to see that. Often children with asymmetry tilt their head, so you may need to straighten him up to fully appreciate the location of the asymmetry—but it’s important to notice it and surprisingly easy to overlook it. Don’t assume it’s just a shift on closure of the mandible. Is the asymmetry present with the jaws slightly separated in the postural position? Does the asymmetry increase on opening?
If so, comprehensive evaluation is needed by a team with experience in treating problems of this type. Growth guidance will be required, either before or after orthognathic surgery depending on the cause of the asymmetry.
Orthodontic Triage, Step 2
The second step in orthodontic triage is examination of the facial profile.
If there is an anteroposterior (skeletal Class II/III) or vertical jaw discrepancy (short/long face), a severe problem exists. Cephalometric analysis and probably growth guidance are indicated.
If there is excessive or inadequate support of the lips by the teeth, cephalometric analysis and major tooth movement, perhaps after extraction of teeth, will be required.
Either a jaw discrepancy or abnormal lip support are severe problems that will require complex treatment. These findings from profile analysis suggest early complete evaluation including cephalometric analysis.
Orthodontic Triage, Step 3
The third step is to examine the dentition and dental (panoramic) radiographs for signs of abnormal development. Congenitally missing permanent teeth and failure of eruption of multiple teeth, which fortunately is rare,are severe problems. Mild asymmetry in the maturation of the teeth is not a problem, but major asymmetry (one side behind the other by a year or more) is.
Supernumerary teeth complicated by number or position constitute a severe problem, because surgical removal can be complex, and multiple teeth may have to be repositioned after the supernumeraries are removed. A single supernumerary in an uncomplicated position is not a severe problem—it can just be extracted, and is not an indication for referral to an orthodontist. In most cases, that’s also true for ankylosed primary teeth and ectopic eruption.
Orthodontic Triage, Step 4
The final step is space analysis. Note that this is done only if the jaw relationships and the pattern of dental development are normal—children with skeletal problems and major dental abnormalities have been separated out previously. Space analysis assumes that skeletal and dental development are normal. It should be used only for children who meet that assumption.
If a primary tooth has been lost prematurely and space is adequate, space maintenance is indicated. If a small space discrepancy has developed, space regaining in the mixed dentition is appropriate treatment in family practice. But a large discrepancy cannot be managed in that way—comprehensive treatment will be required.
If the dentition is intact but the incisors are irregular, the magnitude of the space discrepancy determines how severe the problem is. A small midline diastema is not a severe problem—often it will close spontaneously as the canines erupt—but a large diastema usually requires both careful space closure with control of overbite and long-term fixed retention.
So Who Treats Which Problems?
So who treats which orthodontic problems?
Obviously, that depends in part in the family dentist’s level of interest and expertise in orthodontics. The more you know, and the more you like to do that type of treatment, the more orthodontic patients you will select to treat yourself and vice versa. But there are two explicit guidelines:
- Children with skeletal problems in general, and those with facial asymmetry problems in particular, are candidates for referral.
- The more severe the crowding and protrusion, the greater the chance that referral to a specialist will be good judgment.
Decisions about orthodontic procedures for adults follow a similar logic to the triage for children. The special aspects of orthodontics for adults are reviewed in the companion teaching programs on adjunctive and comprehensive treatment for adults.
Now let’s think about the timing of referral.
If Referral Is Indicated, At What Age Do You Do It?
A second important question is the appropriate age for referral of children.
The general rule is that treatment of Class II and vertical skeletal problems is most effective and efficient if done during the adolescent growth spurt, so you always want to refer children with these problems by the beginning of adolescence. Remember that it’s the stage of physical development that’s important, not the stage of dental development. Get them to the orthodontist before they are sexually mature. Many girls now undergo adolescence at surprisingly early ages.
The girl in image 1 isn’t quite 11, but she’s showing definite signs of puberty. Treatment for her Class II malocclusion, which you can see is largely due to mandibular deficiency, should start now. Waiting for eruption of the remaining permanent teeth would be a serious mistake.
For children with normal jaw proportions but crowding/malalignment, the best time for treatment is just at the end of the mixed dentition, beginning as the second primary molars are ready to exfoliate (images 2,3). Often it is advantageous to maintain leeway space that otherwise would be lost when the second primary molars are lost, and this can be done by beginning treatment just before the remaining permanent teeth erupt. For these patients there is no need to attempt to modify skeletal growth, so the timing can be based on the dentition—but don’t wait until the second primary molars have exfoliated.
 Image 1, Class II: Refer a child with a skeletal problem before the adolescent growth spurt begins. |  Image 2, Class I crowding: Class I crowding: Treatment should begin just at the end of the mixed dentition. |
 Image 3, Class I radiograph: Class I crowding: Treatment begun just at the end of the mixed dentition. |
Age of Referral (cont.)
What types of patients should be referred in the early mixed dentition, well before the beginning of adolescence? In general, those for whom there are special concerns:
- Psychologic difficulties from being teased at school, as children with protruding teeth often are (most but not all are able to cope with this during preadolescent years)
- Trauma to the teeth or soft tissues (image 1)
- Skeletal Class III problems
In general also, treatment for children who have both vertical and a-p jaw discrepancies (the short face Class II child, for instance) may be more effective if it starts prior to adolescence. These children should be referred for evaluation early even if the ultimate decision is to delay treatment until the adolescent growth spurt.
A particular indication for early referral is a Class III problem due to deficient growth of the maxilla. A child with obvious maxillary deficiency, like the boy shown in image 2, should be referred at age 6 or 7 if possible, because the window of opportunity to change growth of the upper jaw without surgery begins to close at about age 8.
In summary: If in doubt, go ahead and refer a preadolescent child for more detailed evaluation. But don’t send them all at age 7, because the majority won’t benefit from treatment until they are approaching adolescence. This important topic is discussed in more detail in the computer program Timing of Orthodontic Treatment.
 Image 1, trauma from overbite: Trauma to the soft tissues, as in this 8-year-old with an impinging overbite, is an indication for early (preadolescent) treatment. |  Image 2, maxillary deficiency: Maxillary deficiency in a 6-year-old is an indication for early referral and treatment. |
How Do You Manage the Referral?
If you’re not in orthodontic practice, you will have orthodontists as colleagues in the local dental community, and will develop a personal relationship with at least some of them.
The style of referral will vary depending on that personal relationships, but three things need to happen:
- a discussion with the parents as to why and to whom you are making the referral
- communication with the orthodontist in advance, so that any pertinent records from your office are available when the orthodontist sees the child
- feedback from the orthodontist to you as to what he or she is recommending, and why
Referral Interactions
How Do You Manage the Referral?
If you’re not in orthodontic practice, you will have orthodontists as colleagues in the local dental community and will develop a personal relationship with at least some of them.
The style of referral will vary depending on that personal relationships, but three things need to happen:
- A discussion between you and the parents as to why and to whom you are making the referral
- Communication with the orthodontist in advance, so that any pertinent records from your office are available when the orthodontist sees the child
- Feedback from the orthodontist to you as to what he or she is recommending, and why
Before seeing the child for the first time, the orthodontist would like to know from you:
- Whether there are special problems with this child/family (including the social setting)
- Whether there have been any problems with other dental treatment, especially problems that might affect future orthodontic treatment
- Whether you have taken radiographs recently that would be useful during the orthodontic evaluation. If so, of course, copies of those radiographs are needed and should be sent in advance if possible.
What Does the Orthodontist Want From You?
Before seeing the child for the first time, the orthodontist would like to know from you:
- whether there are special problems with this child / family (including the social setting)
- whether there have been any problems with other dental treatment, especially problems that might affect future orthodontic treatment
- whether you have taken radiographs recently that would be useful during the orthodontic evaluation.
Your recent panoramic radiograph would be quite useful, and probably would be used instead of taking another one at the orthodontic office. Previous pans also would be useful, and so would periapical radiographs taken to evaluate possible eruption problems or pathology. Copies of those radiographs should be sent in advance if possible. In the modern world, attaching digital radiographs to an email message makes this quick and easy.
Initial Report from the Orthodontist
What should you expect as feedback from the initial visits to the orthodontist? Three things:
- A report of the findings from the patient’s evaluation and the recommendations for treatment or recall in the specialty practice. This typically goes to both the referring dentist and the parents.
- Suggestions for related treatment that you should perform (for example, the removal of primary teeth, placement of a lingual arch to maintain space, etc.).
- Copies of radiographs made as part of the orthodontic evaluation that would be useful in your practice (for example, the panoramic radiograph that would be needed if primary teeth are to be removed early).
The report from the orthodontist can be as detailed—or as short and to the point—as the two of you prefer, so long as the above goals are met. It is easy now to include prints of digital photographs in correspondence or as email attachments. Some dentists find this helpful. Others see it as a waste of time and space in charts.
A typical letter to the referring dentist after the orthodontist’s initial evaluation of the patient (taken from the private practice of a UNC faculty member) is shown in images 1 and 2, with the sections of the single page blown up for easier reading.
After a treatment plan is established, it is shared with the referring dentist (images 3-5).
 Image 1, feedback letter, top: Initial feedback letter from orthodontist, top. |  Image 2, feedback letter, continued: Initial feedback letter, continued. |
 Image 3, treatment plan report: Treatment plan report. |  Image 4, treatment plan report, top: Treatment plan report, top section. |
 Image 5, treatment plan report, cont.: Treatment plan report, cont. |
Reports from the Orthodontist (cont.)
What should you expect from the orthodontist while the child is in orthodontic treatment? At least two things:
- An emphasis by the orthodontist on regular visits to your office for prevention/control of dental disease
- Copies of radiographs or other records that would be useful in your practice, which often will be received with a request to carry out specific treatment procedures
A typical letter reporting progress in treatment and requesting that you see the patient for a specific procedure might look like images 1 and 2. Note that a copy of the orthodontist’s current panoramic radiograph is attached.
Increasingly, instead of a formal letter, communication is in the form of an e-mail message with images attached (images 3 and 4)—which has the advantage of getting the information from one office to another instantly and provides it in digital form that makes it easy to add both text and images to a digital chart.
 Image 1, complete letter: Feedback letter during treatment, requesting extractions. |  Image 2, blow-up of top: Blow-up of top part of letter, for easier reading. |
 Image 3, blow-up of bottom: Blow-up of bottom of letter, for easier reading. |
What Does the Orthodontist Expect from You?
What does the orthodontist expect from you during active orthodontic treatment? At least three things:
- Regular recalls in your office to monitor the patient’s health status
- Treatment as needed for any nonorthodontic problems (for instance, placement of sealants in deep occlusal grooves of second molars as they erupt)
- Communication about who is to do what. For example, if a fluoride rinse or chlorhexidine application to control decalcification is needed, there should be no doubt about who is providing it and supervising its effectiveness.
Coordination of Orthodontic and Other Dental Treatment
Treatment Coordination for Children: Caries/Decalcification
When a child is under orthodontic treatment, three aspects of treatment coordination between the family practitioner and orthodontist require special attention.
1. Control of Caries and Decalcification
The orthodontist tells children and parents, “Braces don’t cause tooth decay, but all the stuff that can collect around the braces can cause it. So you have to keep your teeth really clean.”
A child should have topical fluoride application before treatment begins and should have regular recalls in the family practice or pediatric practice while under treatment, to monitor oral health. When decalcification is a problem, the family practitioner or pediatric dentist can play an important role in reinforcing the importance of good oral hygiene. He or she also may wish to coordinate the use of additional caries control measures like chlorhexidine or fluoride varnishes. If decalcification is noted (image 1), control measures like fluoride varnish are indicated (image 2).
 Decalcification around bonded brackets can be a problem. |  Fluoride varnish can help in controlling decalcification. |
Treatment Coordination for Children: Extractions
Aspects of treatment coordination between the family practitioner and orthodontist that require special attention:
2. Timing and Management of Necessary Tooth Extractions
Extraction of retained primary teeth often is required, and the family practitioner or pediatric dentist should expect to be asked to do this for many child patients. A specific extraction order would be sent, along with recent radiographs (typically, panoramic radiograph).
If permanent teeth are extracted for orthodontic reasons, it is important to place appliances and begin controlled space closure soon thereafter. An exception is the removal of premolars so that canines can erupt in severely crowded mouths. Unless a tooth is erupting in an area of the alveolar process, or one is being moved into that area, bone loss begins quite rapidly, so when extraction spaces are to be closed, it is important to start moving teeth with minimal delay to minimize the loss of alveolar bone.
The general guideline is that the orthodontist will need to see the patient for treatment not more than a month after extraction of permanent teeth or primary teeth with no permanent successor. Beginning the active orthodontics sooner than that is ideal.
 Image 1, pre-tx: Severely crowded lower arch, 1st premolars to be extracted to provide space for canines. |  Image 2, start tx: Three weeks later, during the optimum time period to start treatment: orthodontic appliance in place and tooth movement beginning. |
Treatment Coordination for Children: Retainers and Restorations
Aspects of treatment coordination between the family practitioner and orthodontist that require special attention:
3. Retainers and Restorations
When active orthodontics is completed, retainers are required routinely. Restorations of any type are likely to change the contour of the teeth, and then retainers may not fit.
A particular problem exists when a missing tooth is replaced temporarily with a tooth on a removable retainer. This girl had congenitally missing maxillary laterals; space was opened for prosthetic replacements, and when the braces were removed at age 14, she had a retainer with replacement teeth initially. After 4 months, temporary bonded bridges were placed, and a new retainer without teeth (to be worn just at night) was made immediately. It would not be good judgment for her to wear a retainer with replacement teeth all the time for several years, waiting for the end of vertical growth so that implants could be placed.
With this or other types of posttreatment restorations, appointments must be coordinated so that impressions for the new retainer are taken immediately. Either the child goes directly to the orthodontist after the restorations are placed, or the restorative dentist takes the impression and sends it to the orthodontist for retainer design and fabrication. A delay of more than a few days can produce major problems.
 Image 1, pre-tx: Age 12, prior to treatment to open space for prosthetic replacement of missing maxillary laterals. |  Image 2, bonded bridges: Age 14, 4 months after completion of active treatment, new bonded bridges in place, new retainer required immediately at that point. |
Treatment Coordination for Adults: Retainers and Restorations
The same points in coordination that are important for children, for example, the timing of orthodontics when space is to be closed after extractions, also are important for adults. As in children, space closure in adults should start within the first month after the extractions, and earlier is better.
An important point in the treatment of adults is the timing of fixed restorative treatment after the orthodontics is completed. Although the orthodontist will make retainers at the time the braces are removed, bridges or crowns that provide permanent retention should be placed as soon as possible. Long delays in making the final restorations greatly increase the chance of problems, because teeth can drift if the patient does not wear removable retainers well or if a temporary fixed retainer is broken.
For this patient, both the maxillary left canine and mandibular left central incisor were extracted when she was a child because the dental arches were crowded—not a good approach to crowding problems. Oversized crowns on two lower incisors were not a satisfactory solution, and the space of the missing maxillary canine was partially open, with drift of the maxillary incisors
The orthodontic plan was to open space so that the missing teeth could be replaced. The fixed bridges were placed within a few weeks after removal of the orthodontic appliances. Temporary removable retainers with prosthetic teeth should be replaced with the permanent retainers (bridges or implant-supported crowns) as soon as possible.
 Image 1, pre-tx: Prior to treatment, after ill-advised extractions as a child. |  Image 2, bridges in place: Bridges in place as permanent retainers. |
Summary
In deciding whether a child has a problem that warrants consultation with an orthodontist, you must start with examining facial symmetry/proportions and jaw relationships. The simple rule: If it’s noticeably asymmetric or disproportional, or if the jaw relationships are improper, there’s a skeletal problem that should be evaluated. Then you can examine the dental alignment and occlusion. The more severe the malocclusion, the greater the chance that referring the patient to a specialist would be good judgment.
For treatment of skeletal Class II and vertical problems, the adolescent growth spurt is the best time for treatment. Remember that this may precede the eruption of the canines and premolars, especially in girls. A special indication for early treatment to modify growth is maxillary deficiency that produces a Class III malocclusion. Face mask treatment should start before age 8 if at all possible; Class III elastics to bone anchors should start at age 10/12 to 11, at the very beginning of adolescence.
Good communication in both directions is the key to good patient management when a patient from your practice goes to an orthodontist. It is important for the patient to have regular appointments in the referring dentist’s practice while undergoing orthodontics, to monitor oral health.
Coordinated treatment is needed in several situations:
- Caries/decalcification control. Guideline: Monitor carefully, use additional control measures if there are signs of problems.
- Extractions. Guideline: Orthodontic space closure should start within one month after the extractions are done.
- Retainers/restorations. Guideline: Posttreatment restorations should be done as soon as possible after the braces come off. Temporary retainers are used until the final restorations are completed. New retainers, typically then for part-time wear, should be made as soon as the final restorations are completed, because the previous ones won’t fit satisfactorily any more. For adults, fixed bridges and implant-supported crowns become an effective type of permanent retainer.
Self-Test Referral
The self-test section of this program is designed to help you be sure you have understood the material. Do the assigned reading (Contemporary Orthodontics, 5th ed: pages 368-369, 652-660; 4th ed: pages 662-672). Then take the test, and use it as a guide for further study and review.
Copyright 2013, UNC Dept. of Orthodontics
Self-Test
Question 1
Which of the following are reasons that a relatively higher percentage of orthodontic treatment is done in specialty practice?
a. Early development of specialty
b. Less emphasis in dental school
c. Efficiency in practice relative to instruments/materials
d. Positive social interaction
- a and b
- b and c
- a, b, and c ✓
- b, c, and d
- all of the above
Correct
That’s right, three of these possibilities affect the number of patients referred to specialty practice: the early development of orthodontics as a specialty due to Edward Angle’s influence, less orthodontic clinical experience in dental school, and efficiency relative to supplies and materials. Social interaction has little or nothing to do with it.
Incorrect
No, that’s incorrect. Three of these possibilities affect the number of patients referred to specialty practice: the early development of orthodontics as a specialty due to Edward Angle’s influence, less orthodontic clinical experience in dental school, and efficiency relative to supplies and materials. Social interaction has little or nothing to do with it.
Question 2
Which is the most important reason that an obvious jaw asymmetry in a child is a reason for early referral?
- The asymmetry may be due to a congenital anomaly.
- The asymmetry is likely to be due to a condylar fracture or injury.
- The asymmetry can be a progressive deformity that steadily gets worse. ✓
- Growth modification is the probable treatment.
- The child may need surgery to create the possibility of future growth.
Correct
That’s right, all these statements are correct, but the most important reason for early referral is the possibility that the asymmetry is a progressive deformity, one that gets steadily worse as the affected area does not grow and other normal areas do. Early evaluation is important, and early surgery may be needed.
Incorrect
No, that’s wrong. All these statements are correct, but the most important reason for early referral is the possibility that the asymmetry is a progressive deformity, one that gets steadily worse as the affected area does not grow and other normal areas do. Early evaluation is important, and early surgery may be needed.
Question 3
In the analysis of facial proportions, the “rule of thirds” means that
- one-third of children have disproportions in facial dimensions.
- one-third of children have normal proportions.
- nasal height equals the thirds of the face above and below the nose. ✓
- the lower third of the face should be longer than the areas above.
- the upper third of the face can be ignored when orthodontics is planned.
Correct
That’s right, nasal height constitutes the middle third of the face, and it should be the same size as the upper third (hairline to bridge of nose) and lower third (base of nose to chin). All the other possible answers are simply wrong.
Incorrect
No, that’s incorrect. Nasal height constitutes the middle third of the face, and it should be the same size as the upper third (hairline to bridge of nose) and lower third (base of nose to chin). All the other possible answers are simply wrong.
Question 4
Triage is the process of
- breaking the life span into three sections.
- sorting patients by problem severity. ✓
- determining which patients should be referred immediately.
- determining which patients eventually will need referral.
- all of the above
Correct
That’s right, triage is the process of sorting patients by problem severity. In its military application, it is used to sort casualties after battles so that those who would most benefit from prompt treatment are treated first. Similar thinking determines which children would be referred for more complete evaluation at an early age.
Incorrect
No, that’s wrong. Triage is the process of sorting patients by problem severity. In its military application, it is used to sort casualties after battles so that those who would most benefit from prompt treatment are treated first. Similar thinking determines which children would be referred for more complete evaluation at an early age.
Question 5
The major reason for referral of children with a craniofacial syndrome to a craniofacial team is
- correct syndrome diagnosis allows prediction of future growth. ✓
- behavior management is likely to be a particular problem with these children.
- early treatment often is needed.
- the probability of early jaw surgery is high.
- parents of such children can be particularly demanding and difficult.
Correct
That’s right, it’s important to obtain a correct syndrome diagnosis as early as possible, because this allows much better prediction of future growth and development and therefore is an important guide to treatment planning. Whether the other statements are true depends on the individual case. They aren’t true for all (or even the majority) of children with craniofacial syndromes.
Incorrect
No, that’s wrong. It’s important to obtain a correct syndrome diagnosis as early as possible, because this allows much better prediction of future growth and development and therefore is an important guide to treatment planning. Whether the other statements are true depends on the individual case. They aren’t true for all (or even the majority) of children with craniofacial syndromes.
Question 6
What of these is the major reason for referral of a child with obvious protrusion of the incisors on profile examination?
- Cephalometric analysis and monitoring are needed. ✓
- Extraction of teeth and space closure probably is required.
- Opening the midpalatal suture may be necessary.
- Treatment probably will take more than 2 years.
- If protrusion is obvious, there’s no need for referral.
Correct
That’s right, the major reason in this list for referral of a child with obvious protrusion of the incisors is that cephalometric analysis is needed to plan tooth movement for children of this type. Cephalometric analysis also can help determine the best time for treatment, may allow a comparison of the probable outcomes of alternative treatment possibilities, and is required for monitoring the progress of treatment.
Incorrect
No, that’s wrong. The major reason in this list for referral of a child with obvious protrusion of the incisors is that cephalometric analysis is needed to plan tooth movement for children of this type. Cephalometric analysis also can help determine the best time for treatment, may allow a comparison of the probable outcomes of alternative treatment possibilities, and is required for monitoring the progress of treatment.
Question 7
(A) A supernumerary tooth observed on the panoramic radiograph of a child always is a severe problem indicating referral because (B) These teeth may damage other developing teeth or produce asymmetries in the dental arch.
- A true, B true, A and B related
- A true, B true, A and B not related
- A true, B false
- A false, B true ✓
- A and B false
Correct
That’s correct. The first statement is false, but the second one is true. Multiple supernumeraries constitute a severe problem, but a single uncomplicated supernumerary, in the absence of skeletal problems, can just be extracted. By itself, it is not an indication for orthodontic referral.
Incorrect
No, that’s wrong. The first statement is false, but the second one is true. Multiple supernumeraries constitute a severe problem, but a single uncomplicated supernumerary, in the absence of skeletal problems, can just be extracted. By itself, it is not an indication for orthodontic referral.
Question 8
Which of the following best describes the role of space analysis in determining the need for orthodontic referral?
- The bigger the discrepancy, the greater the chance referral is indicated. ✓
- Refer children with >4 mm discrepancy.
- Refer children with excess spacing.
- Refer children with space discrepancy due to early loss of primary teeth.
- All of the above are correct.
Correct
That’s right, there are no hard-and-fast rules about the magnitude of space discrepancy and the need for referral, but in general, the bigger the discrepancy, the greater the chance that referral is indicated. Whether children with >4 mm discrepancy, excess spacing or a discrepancy due to early loss of primary teeth are treated in family practice is very much up to the family dentist’s interest and competence.
Incorrect
No, that’s incorrect. there are no hard-and-fast rules about the magnitude of space discrepancy and the need for referral, but in general, the bigger the discrepancy, the greater the chance that referral is indicated. Whether children with >4 mm discrepancy, excess spacing or a discrepancy due to early loss of primary teeth are treated in family practice is very much up to the family dentist’s interest and competence.
Question 9
For a girl with Class II malocclusion and obvious mandibular deficiency, what’s the best time for treatment?
- Before the adolescent growth spurt
- During the adolescent growth spurt ✓
- Before the end of the mixed dentition
- Not until the permanent second molars are near eruption
- Treatment should coincide with eruption of the maxillary canines
Correct
That’s right. The best time for treatment of most patients with Class II malocclusion is during the adolescent growth spurt, although some children may benefit from earlier treatment. It’s important to plan the timing of referral based on physical development, not dental development. Some girls are well into their growth spurt before canines, premolars, or second molars begin to erupt and need to have treatment started in the mixed dentition. For referral timing, look at secondary sexual characteristics, not the teeth.
Incorrect
No, that’s wrong. These statements are both true, and to some extent they’re related (so either #1 or The best time for treatment of most patients with Class II malocclusion is during the adolescent growth spurt, although some children may benefit from earlier treatment. It’s important to plan the timing of referral based on physical development, not dental development. Some girls are well into their growth spurt before canines, premolars, or second molars begin to erupt and need to have treatment started in the mixed dentition. For referral timing, look at secondary sexual characteristics, not the teeth.
Question 10
Which of the following are indications for early (preadolescent) referral of a girl with Class II malocclusion?
a. Psychologic difficulties related to teasing
b. Trauma to soft tissues from the occlusion
c. Exceptionally severe skeletal discrepancy
d. Anterior open bite combined with the Class II problem
- a and b
- b and c
- a, b, and c
- b, c, and d
- all of the above ✓
Correct
That’s right, all of these are indications for early (preadolescent) referral. Starting treatment prior to adolescence usually means that two phases of treatment will be required, so special indications for treatment should be present before early treatment is recommended.
Incorrect
No, that’s wrong. All of these are indications for early (preadolescent) referral. Starting treatment prior to adolescence usually means that two phases of treatment will be required, so special indications for treatment should be present before early treatment is recommended.
Question 11
Which of the following is the most important indication for early (preadolescent) referral?
- Deep bite Class II
- Open bite Class II
- Crowding > 10 mm
- Maxillary deficient Class III ✓
- Mandibular prognathic Class III
Correct
That’s right, a Class III problem due maxillary deficiency is particularly important for early referral, because the window of opportunity for growth modification in these children closes at age 8 or 9. Waiting for adolescence to refer them will mean that effective growth modification cannot be achieved.
Incorrect
No, that’s wrong. A Class III problem due maxillary deficiency is particularly important for early referral, because the window of opportunity for growth modification in these children closes at age 8 or 9. Waiting for adolescence to refer them will mean that effective growth modification cannot be achieved.
Question 12
Which of the following should you expect in a report from the orthodontist after you have referred a child for evaluation?
a. Diagnostic problem list from the evaluation
b. Treatment recommendations
c. Copies of radiographs
d. Digital photographs
- a, b, and c
- b, c, and d
- a, c, and d
- all of the above ✓
Correct
That’s right, you should expect a diagnostic problem list, treatment recommendations and copies of radiographs that would be useful in your dental practice (which may or may not include cephalometric radiographs, depending on your preference). Unless you have told the orthodontist you don’t want them, you also are very likely to get prints of digital photographs that you can add to your chart.
Incorrect
No, that’s wrong. You should expect a diagnostic problem list, treatment recommendations and copies of radiographs that would be useful in your dental practice (which may or may not include cephalometric radiographs, depending on your preference). Unless you have told the orthodontist you don’t want them, you also are very likely to get prints of digital photographs that you can add to your chart.
Question 13
What is the ideal time for the beginning of orthodontic treatment after you have extracted teeth at the orthodontist’s request?
- Within 10 days
- 2-6 weeks postextraction ✓
- 6-12 weeks postextraction
- Not until at least 3 months have passed
- Doesn’t matter if within the first year
Correct
That’s right, orthodontic space closure should start between 2 and 6 weeks after the extractions. Waiting longer increases the chance of bone resorption at the extraction site that can complicate the space closure and result in alveolar defects long term.
Incorrect
No, that’s wrong. orthodontic space closure should start between 2 and 6 weeks after the extractions. Waiting longer increases the chance of bone resorption at the extraction site that can complicate the space closure and result in alveolar defects long term.
Question 14
If restorations are planned after the orthodontics is completed, how is this treatment coordinated with the orthodontic retainers?
- Retainer immediately after debond, new one immediately after restorations ✓
- Restorations immediately after debond, retainer immediately after restorations
- Retainer immediately after debond, restorations are permanent retainer
- Retainer immediately after debond, new retainer if needed 3 months after restorations
- Retainer doesn’t matter within the first year, make one after restorations if needed
Correct
That’s right, when restorations are planned, a retainer should be placed immediately after the orthodontic appliance is removed (unless the restorations are to be done with a day or so), and as soon as the restorations are completed, an impression for a new retainer should be made. The original retainer won’t fit after the restorations are done, and even if no further retention is needed in the area where the restorations are placed (around a bridge for example), a modified retainer to maintain other relationships almost surely will be required.
Incorrect
No, that’s wrong. When restorations are planned, a retainer should be placed immediately after the orthodontic appliance is removed (unless the restorations are to be done with a day or so), and as soon as the restorations are completed, an impression for a new retainer should be made. The original retainer won’t fit after the restorations are done, and even if no further retention is needed in the area where the restorations are placed (around a bridge for example), a modified retainer to maintain other relationships almost surely will be required.